Well Child Exam-Middle Childhood: 6 - 10 Year Page 2
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4PAGE 2 - WELL CHILD EXAM-MIDDLE CHILDHOOD: 6 – 10 Year – Developmental Surveillance
(This page may be used if not utilizing a Validated Developmental Screener)
DATE
PATIENT NAME
DOB
Developmental Questions and Observations
Ask the parent to respond to the following statements about the child:
Yes
No
□
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Please tell me any concerns about the way your child is behaving or developing:
_______________________________________________________________________
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My child has hobbies or interests that he/she enjoys.
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My child follows rules in home, school and the community, most of the time.
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My child’s behavior, relationships and school performance are appropriate most of the time.
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My child handles stress, anger, frustration well, most of the time.
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My child eats breakfast every day.
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My child is doing well in school.
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My child talks to me about school, friends and feelings.
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My child seems rested when he/she wakes up.
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My child gets some physical activity every day.
Ask the parent to respond to the following statements:
Yes
No
□
□
I know what to do when I am frustrated with my child.
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I enjoy seeing my child become more independent and self-reliant.
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Our family has experienced major stresses and/or changes since our last visit.
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It is harder for me everyday to do what my child needs because of the sadness that I feel.
Ask the child to respond to the following statements:
Yes
No
□
□
I feel good about my friends and school.
□
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I know what to do when another child or adult tries to bully me or hurt me.
Provider to follow up as necessary
Developmental Milestones
Always ask parents if they have concerns about development or behavior. (You may use the following screening list, or a
standardized developmental instrument or screening tool).
Child Development
States phone number and home address
Yes
No
Reading and math are at grade level
Yes
No
Has close friend(s)
Yes
No
Child communicates/expresses self
Yes
No
Child responds to parent and health care
Yes
No
provider
Please note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when the opportunity for
continuing observation is not anticipated. (Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents)
Additional Notes from pages 1 and 2:
Staff Signature: ________________________________________ Provider Signature: ______________________________________
This HME form was developed by the Institute for Health Care Studies at Michigan State University in collaboration with the Michigan Medicaid managed care plans, Michigan
Department of Community Health, Michigan Department of Human Services, Michigan Association of Health Plans, and Michigan Association of Local Public Health.
Updated 4/2011
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